Stimulant Use Disorder Flashcards
Stimulant use disorder (SUD) is classified as…
An inappropriate use of stimulants, leading to clinically significant impairment/distress
Diagnostic criteria as per the DSM defines 3 categories, including…
Problems with USE - using large amounts, more time spent with use, repeated attempts to control use
Problems with LIFESTYLE - physical/psych/social/interpersonal problems related to use, activities given up, neglected major roles, hazardous use
Problems with PHYSIOLOGY - craving, tolerance, withdrawal
Same as OUD
Most stimulants used are derivatives of…
Amphetamine
Stimulants physiological effect is to…
Stimulants are often refered to as…
Increase motivation, concentration, mood, energy, and wakefulness
Sympathomimetics - mimic physiological effects of epinephrine
The cycle of SUD is often…
Binging on stimulant - stimulant wears off = crash - experience cravings, repeat.
Tolerance + addiction end up developing
Strong stimulants include…
Cocaine
Methamphetamine
MDMA
The mechanism of stimulants is…
Increasing CNS + ANS activity
Effect reward pathway by increasing DA concentrations - outcome similar between stimulants, but intensity will vary
Cocaine and amphetamines are stronger stimulants pharmacologically, because…
Cocaine prevents re-uptake only of DA, 5-HT, NE
Amphetamines cause RELEASE of NT (DA, 5-HT, NE) from storage sites, and to various degrees also inhibit re-uptake
Long-term use depletes stores of NT which leads to tolerance
Stimulant effect on the CNS involves…
Intense euphoria
Increased alertness, concentration, talkativeness, sexual behaviour
Decreased appetite, fatigue
May see anxiety, agitation, nausea, tremors, twitches
Stimulant effect on the ANS involves…
Increase in body temperature, heart rate, blood pressure, respiratory rate, constriction of blood vessels (dilated pupils)
Overdose of stimulants can result in…
Seizures, coma, cardiac toxicity, respiratory arrest, brain hemorrhage, death
Immediate complications of stimulants may include…
Increased risk of violent/illegal behaviours
Increased engagement in risky sexual behaviour
Psychosis
Irritability
Long-term complications of stimulants may include…
Dental decay, weight loss, picking at skin with scabs, panic attacks
Brain changes, memory loss
Chronic psychotic disorders
Psychotic disorders can be secondary to repeated use, or unmasking of a primary disorder
A patient with acute stimulant intoxication or overdose may present with the following symptoms…
CNS, ANS overdrive
Mania, psychosis, paranoia, severe delirium
Increased BP, chest pain, agitation, sweating, skin-picking
Stimulant intoxication management is usually…
Supportive, unless patient is experiencing delusions, autonomic hyperactivity, or overtly agitated
Or severe crisis
For stimulant intoxication management, if a patient is acutely agitated, we could…
Consider BZD - lorazepam PRN
If does not help or in presence of psychotic sx’s, could add low dose AP
For stimulant intoxication management, if a patient is experiencing psychotic symptoms, we could…
Give low dose antipsychotic (risperidone 0.5-2mg/day, olanzapine 2.5-7.5 mg/day)
Delusions are often self-remitting without treatment (unless patient has been experiencing them chronically)
For stimulant intoxication management, if a patient is experiencing cardiovascular complications, we could…
Give anti-arrythmic agents if arrythmia present
Give beta-blocker/clonidine for tachycardia +/- HTN
For stimulant intoxication management, if a patient is experiencing seizures, we could…
Give anti-seizure medication if currently seizing (diazepam IV, midazolam IM)
No role in prevention
Stage 1 of stimulant withdrawal starts…
Crash
Within hours, and lasts 4-7 days
Signs and symptoms of stage 1 withdrawal include…
Hypersomnolence
Hyperphagia
Fatigue
Marked dysphoria
Fatigue, anorexia
Stage 2 of stimulant withdrawal starts…
After the first week and can last up to 10 weeks
Signs and symptoms of stage 2 withdrawal include…
1st week is normal (euthymia, little anxiety, minimal craving, normal sleep)
Subsequent weeks - anhedonia, increased anxiety, depression, fatigue
Extreme craving + fixation on use
From a pharm perspective, stimulant withdrawal management is primarily…
Non-pharm: planning for addictions counselling, support, community support, rehab options, housing needs
If post-acute hyperarousal/anxiety persists in stimulant withdrawal, we could…
Continue BZD’s for a little longer
Trial mirtazapine (mixed results)
Goals of therapy in treating SUD include…
Achieving abstinence
Maintaining abstinence (tx ongoing withdrawal, craving, addictions)
Treating comorbid conditions (depression, anxiety)
Preventing harm to self and others
Sustained neurophysiological changes from methamphetamine usage leads to…
Depressed mood
Anhedonia
Cognitive impairment
Poor health
The biggest factor leading to relapse and challenges in managing SUD is…
Cravings
Antidepressants were thought to help with SUD because ____, BUT…
5-HT may attenuate reinforcing effects of amphetamine and counter withdrawal symptoms of depression, but mixed results have been seen with abstinence
Mirtazapine had 1 positive RCT for amphetamine abstinence, but still not solid evidence
Bottom line: antidepressant usage for abstinence is…
Mostly ineffective, but may have positive mood-related results. Use according to depression/anxiety guidelines if indicated
Rationale for AP usage in SUD was ____, however…
They could counterbalance excess DA actvitity and restore NT pathways; however risked promoting cravings due to decreased dopamine increasing negative symptoms
AP’s efficacy in SUD treatment showed…
No difference in any treatment outcomes (tx retention, abstinence, reduced use)
Aripiprazole showed increased cravings and use, likely due to impulse control issue
We should use AP’s in SUD treatment if…
Indicated, according to psychosis guidelines. Review need after 6 months.
Rationale for considering prescribed stimulants for SUD was…
Substitution/replacement therapy, similar to OAT
Studies have shown that prescribed stimulants for SUD was…
Mixed results - possible reduction in use or cravings, but usually no difference in treatment outcomes were observed
Generally not recommended due to risk of worsening psychosis, and mood lability
Rationale for considering dopamine agonists in SUD was that…
Chronic stimulant use led to DA depletion
Studies have found that dopamine agonists….
General results were not promising - some possible benefit in severe withdrawal
Evidence of modafinil is SUD is…
Mixed - possibly useful to reduec cocaine use, but has negative trials and risk of increased effect with concurrent stimulant usage.
Evidence for bupropion + naltrexone is…
Statsitically significant compared to placebo; but still has a low response rate overall
Mainstay of tx for SUD is…
Non-pharm: 1st line = psychosocial approaches (CBT, contingency management, addictions treatment)
Know where we can refer patients to
The pharmacist role in SUD is…
Elimination of unnecessary/non-beneficial medications
Elimination of harmful medications (long term BZD, stimulants)
Help identify + treat comorbid mental or physical conditions
For other conditions treat according to guidelines independent of substance use, but also consider individual risk factors
